|
Gynecologic History
|
|
|
Date of LMP
|
Menstrual Problems
• • •
|
|
Menstrual Freewrite
|
|
|
Last Pap
|
Previous Abnormal Pap Tests
• • •
|
|
Pap Freewrite
|
|
|
Method of Birth Control
• • •
|
Birth Control Problems
• • •
|
|
Birth Control Freewrite
|
|
|
Infections of uterus, ovaries, t
• • •
|
Infections Freewrite
|
|
DES Exposure
|
|
|
Endometriosis
• • •
|
Endometriosis Freewrite
|
|
Infertility
|
Infertility Freewrite
|
|
History of Cancer
• • •
|
Cancer Freewrite
|
|
Abnormal Bleeding
• • •
|
Abn Bleeding Freewrite
|
|
Breast Problems
• • •
|
Breast Problems Freewrite
|
|
Obstetric History
|
|
|
Year
|
City/State
/
|
|
Length of Pregnancy
|
Hours in Labor
|
|
Complications of Pregnancy/Labor
|
Type of Delivery
• • •
|
|
Sex M/F
• • •
|
Birth Weight(s)
• • •
|
|
Year
|
City/Sate
/
|
|
Length of Pregnancy
|
Hours in Labor
|
|
Complications of Pregnancy/Labor
|
Type of Delivery
• • •
|
|
Sex M/F
• • •
|
Birth Weight(s)
• • •
|
|
Year
|
City/State
/
|
|
Length of Pregnancy
|
Hours in Labor
|
|
Complications of Pregnancy/Labor
|
Type of Delivery
• • •
|
|
Sex M/F
• • •
|
Birth Weight(s)
• • •
|
|
Year
|
City/State
/
|
|
Length of Pregnancy
|
Hours in Labor
|
|
Complications of Pregnancy/Labor
|
Type of Delivery
• • •
|
|
Sex M/F
• • •
|
Birth Weight(s)
• • •
|
|
Year
|
City/State
/
|
|
Length of Pregnancy
|
Hours in Labor
|
|
Complications of Pregnancy/Labor
|
Type of Delivery
• • •
|
|
Sex M/F
• • •
|
Birth Weight(s)
• • •
|
|
Medical History
|
|
|
Past Medical History
• • •
|
Past Medical History Freewrite
|
|
Childhood illnesses
• • •
|
Comments
|
|
Childhood Immunizations
• • •
|
Comments
|
|
Cancer
• • •
|
Comments
|
|
Heart Disease
• • •
|
Comments
|
|
High Blood Pressure
|
Comments
|
|
Varicose Veins
|
Comments
|
|
Thrombophlebitis
|
Comments
|
|
Ulcers
|
Comments
|
|
Hepatitis
|
Comments
|
|
Colitis
|
Comments
|
|
Gallbladder Disease
|
Comments
|
|
Diarrhea/Constipation
• • •
|
Comments
|
|
Rectal Bleeding
|
Comments
|
|
Hemorrhoids
|
Comments
|
|
Seizures/Epilepsy
• • •
|
Comments
|
|
Migraines
|
Comments
|
|
Asthma
|
Comments
|
|
Pneumonia
|
Comments
|
|
Bronchitis
|
Comments
|
|
Tuberculosis
|
Comments
|
|
Bladder/Kidney Infections
• • •
|
Comments
|
|
Blood in Urine
|
Comments
|
|
Urine Loss with Cough/Sneeze
• • •
|
Comments
|
|
Anemia
|
Comments
|
|
Bleeding Problems
|
Comments
|
|
Previous Transfusions
|
Comments
|
|
Diabetes
• • •
|
Comments
|
|
Thyroid Disease
|
Comments
|
|
Arthritis
• • •
|
Comments
|
|
Mononucleosis
|
Comments
|
|
Rubella
|
Comments
|
|
Stroke
• • •
|
Comments
|
|
Paralysis
|
Comments
|
|
Tobacco
• • •
|
Comments
|
|
Alcohol
|
Comments
|
|
Other substances
|
Comments
|
|
Caffeine
|
Comments
|
|
Patient's diet
|
|
|
Date of last PE
|
Comments
|
|
Medical Allergies
|
|
|
Medical Allergies
|
Reactions
|
|
Present Medications
|
|
|
Surgical History
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
|
|
|
Family History
|
|
|
Father's MH
• • •
|
Comments
|
|
Mother's MH
• • •
|
Comments
|
|
Sibling(s)' MH
• • •
|
Comments
|
|
Grandparent's MH
• • •
|
Comments
|
|
Children(s)' MH
• • •
|
Comments
|
|
|
|
|
Social History
|
|
|
Marital Status
• • •
|
|
|
Living Arrangements
• • •
|
Potential Environmental Pathogen
|
|
Sexual Hx
|
|
|
Occupation
|
Comments
|
